Tackling the Challenges of Breast Reconstruction After Lumpectomy and Radiation

tackling reconstructionThe below question was answered by Charleston breast surgeon, Dr. Richard M. Kline, Jr., MD of The Center for Natural Breast Reconstruction:

I had a lumpectomy in 2002 of the left breast followed with 33 rounds of radiation. I have since had a breast lift and reduction on the sound side in an effort to “even” my breasts. It worked for a while but the left continues to shrink. Any suggestions? Some suggest an implant, but I fear the cancer coming back and not being identified due to the implant.

Implants are indeed known to decrease the effectiveness of mammograms by about 1/3 after breast augmentation, and may well have the same effect when used in reconstruction after lumpectomy. Additionally, implants tend to be more poorly tolerated after radiation, although some people do quite well with them.

A flap of your own tissue could be used to augment your breast, but this would be a fairly large undertaking, usually (but not always) reserved for post-mastectomy reconstruction. Injections of your own fat, while proving to be a very useful adjunct to post-mastectomy reconstruction, are not routinely recommended (yet) for augmenting the lumpectomy defect.

One potentially very useful measure, if available to you, might be a full Marx protocol of hyperbaric oxygen treatment. A large part of the damaging effects of radiation is progressive obliteration of the microvascular circulation (smallest blood vessels). Hyperbaric oxygen (HBO) has been shown to very reliably stimulate the growth of new blood vessels in radiated tissue. Clinically, this often results in fairly dramatic softening of the radiated tissue, and a healthier appearance of the skin.

Thank you for your question.

-Dr. Richard M. Kline Jr., MD

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Handling Breast Implant Infections: What You Need to Know

Dr. James CraigieThe below question is answered by Charleston breast surgeon Dr. James Craigie of The Center for Natural Breast Reconstruction.

What is the usual process for handling infections with breast reconstruction when tissue expanders are used?

Infections can occur following any type of surgery. The risk of getting an infection after breast reconstruction is low because the immune system can help defend the body from bacteria if they have invaded and are trying to multiply. Antibiotics can also be used, specifically to fight different types of bacteria, following certain surgical procedures. These antibiotics are sometimes given preventively.

When an infection does occur it is because the defense mechanisms have been compromised and the invading bacteria grow. Specifically with implants the bacteria may enter through a wound healing problem. They attach to the implant shell and hide from the bloodstream that normally delivers the body’s immune response, as well as antibiotics.

The management of this type of infection is difficult and almost always requires removing the implant. When the infection resolves and the area is healthy, then it is possible to restart the process. Usually it is 3 to 6 months before it is safe to try another implant. It is occasionally possible to save the implant when the infection has been caught early and treated with antibiotics and surgery to wash the implant pocket and to put a new one in. This approach usually involves antibiotics for a long time and uncertainty about recurrence of the infection weeks or months later when the powerful antibiotics have been discontinued.

It is important to realize that the antibiotics may resolve the outward signs of infection at first, but it only takes the surviving bacteria hiding on the implant to restart the infection when the antibiotics have been discontinued. With each new infection the bacteria may become more difficult to control because of resistance to the antibiotics. At this point, it is usually my advice to consider a new option for breast reconstruction that does not involve an implant. Usually the skin and fat can be transferred from the tummy, buttock or thighs. This can be done without sacrificing any of the important muscles. In my practice, 30 % of my patients have had problems with implants and we can successfully replace implant problems with healthy tissue and obtain a permanent natural result.

—Dr. James Craigie

Breast Reconstruction Surgeons Answer Your Questions About Reconstructive Surgery

reconstruction optionsThe question below is answered by Charleston breast surgeons Dr. James Craigie and Dr. Richard M. Kline, Jr., of The Center for Natural Breast Reconstruction.

What is the difference between breast reconstruction and augmentation?

Breast augmentation is when you increase the size of a normal healthy breast, almost always with saline or silicone gel implants.

Breast reconstruction is restoring the form of a breast that has been damaged, partially removed, or completely removed. Breast reconstruction is almost always done after treatment for breast cancer, although there are some birth defects that can result in the need for breast reconstruction. Breast reconstruction can be performed with implants (the same ones used for breast augmentation), or with the body’s own excess tissue (usually from the abdomen or buttocks), thus avoiding the need to place foreign objects in the body.

What are the pros and cons of a DIEP versus a TRAM flap reconstruction?

The primary advantage of DIEP flaps over TRAM flaps is a far greater potential for preservation of rectus abdominus muscle function, since no muscle is removed with a DIEP, yet one or both rectus muscles is obligatorily completely sacrificed with every TRAM flap. Additionally, since the muscle does not need to be tunneled under the skin to reach the breast area with a DIEP, the shape of the inferior region of the breast can be better defined.

The primary advantage of the TRAM flap over the DIEP flap is that it can be done by one surgeon who does not have the skills or equipment (microscope and special instrumentation) to perform a DIEP flap. While TRAM flaps can sometimes be performed more quickly than DIEP flaps, this is not always the case, and is very dependent upon the skills and experience of the surgeon. In our practice, DIEP flaps are always performed with two fully-trained perforator flap surgeons present, which we believe contributes greatly to the success and timely completion of the surgeries.

Why don’t more plastic surgeons offer the DIEP procedure?

When the DIEP flap was originally presented by Dr. Robert Allen in the 1990s, it was frequently criticized as being too difficult for many surgeons to learn to perform easily. While many more surgeons now offer the DIEP flap, it is still more technically demanding for the surgeon than many other procedures, and can be quite difficult to learn without spending significant time with another surgeon who has considerable experience with the operation.

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How Can I Alleviate Scar Pain and Tightness After Surgery?

The question below is answered by Charleston breast surgeon, Dr. Richard M. Kline, Jr. of The Center for Natural Breast Reconstruction.

I had a Phase 1 SIEA flap reconstruction in February 2010, and a Phase 2 in November 2010. Abdominal and drain scars were revised in November 2010, but I’m still having severe pain, tightness, and discomfort, including bad scarring on part of the big abdominal incision and on both abdominal drain sites. I’m assuming that I need another surgery (I’m seeing my plastic surgeon soon). Is it correct to assume there’s a chance any new revisions might not work? And are there any techniques that could alleviate some of the abdominal tightness?

I’m sorry that you are experiencing a rare, but, unfortunately, persistently recurring, complication – not specifically of breast reconstruction surgery, but of any surgery.

Any time skin or other body structures are cut, myriad nerves, a few named, most unnamed, are unavoidably divided, or at least damaged. Most of the divided or damaged nerves “wither away,” and cause no problem. A very few of the damaged nerves stay “irritated,” and some of the divided nerves form “neuromas,” or very tender balls of nerve tissue. These account for much of the chronic pain, which some people experience following surgery. Why this occurs when it does, and how to predict or prevent it, are questions all surgeons would love to know the answer to. It is not preventable – the best a surgeon can do is warn patients that it could happen.

As a practical matter, re-operating for painful scars may not be very productive. When our patients have chronically painful surgical sites, we refer them to pain management specialists for treatment. Usually this involves injections of local anesthetics, steroids, or other agents. We have generally been pleased with the results we have seen from this.

If there are other reasons to revise your surgical site, it is not completely unreasonable to think that more surgery may favorably affect the pain, and we wish you the best of luck in that scenario.

–Dr. Richard M. Kline, Jr.

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